Global Trigger Tool Program at Melbourne Health

Exclusion Criteria o Admitted for less than two days o Below 18 years of age o Admitted under Mental Health o Admitted for subacute care

Sensitivity and Specificity Attributes of the nurse screening process (n=260 records) were: o sensitivity 97.2%; o specificity 98.7%; o positive predictive value 98.1%; and o negative predictive value 98.0%.

Understanding the Nature of AE o Florida Hospital categories of harm: Surgery or Other Procedure Medication/Intravenous Fluids Patient Care Hospital Acquired Infection Other These are further divided into subcategories of harm

Results following 42 Audit Cycles (n= 420 records) o Adverse events per 1000 bed days: 80.3/1000 bed days o Adverse events per 100 admissions: 39.5/100 admissions o % of admissions with an adverse event: 32.1%

Results following 42 Audit Cycles (Continued) Distribution of adverse events by level of harm : SeverityCount% E: Temporary harm requiring intervention11066% F: Temporary harm requiring initial or prolonged hospitalisation5332% G: Permanent harm21% H: Intervention required to sustain life00% I: Death11% Total166

Results following 42 Audit Cycles (Continued) AE by Category and Severity of Harm: Harm Category Adverse Events Severity EFGHI Surgery or Other Procedure Medication/IV Fluids Hospital Acquired Infection Patient Care Other Total

Results following 42 Audit Cycles (Continued) Example of Sub-Harm Category: Frequency by Period Cycle 1 to 42Cycle 37 to 42 (Q7) Hospital Acquired Infection Sub-Harm Category Adverse Events% % Surgical infection844%00% Ventilator associated pneumonia317%00% VRE211%00% Clostridium difficile211%00% Central line associated bloodstream infection16%00% Catheter associated UTI16%00% Other16%1100% Total18 1

Database

Lessons Learnt o Have a database developed at start of program o Minimise staff turn over for consistency o Meaningful analysis of data - Use of the Florida Hospital harm categories and subcategories helps to make data more meaningful o Reporting - Present data in such a way that it is meaningful to clinical staff as part of a balanced safety measurement framework o Develop a clear communication plan - including feedback to coalface staff and action committees e.g. Skin Integrity; Infection Prevention, etc

Contact Details Sharon Walsh National Standards and Clinical Governance Coordinator Phone: